F0656

D

Care Plan Not Updated to Reflect Resident’s Current Therapeutic Diet

Edinburg, Texas Survey Completed on 03-13-2026

Penalty

No penalty information released

Summary

Surveyors identified a failure to develop and implement a comprehensive, person-centered care plan that reflected a resident’s current diet order. The resident was an elderly male with multiple diagnoses including cerebral infarction, chronic heart failure, type 2 diabetes, dementia, urinary tract infection, hypertension, muscle wasting and atrophy, dysphagia, and lack of coordination. His MDS assessment showed a BIMS score of 1, indicating severe cognitive impairment, and documented the need for a mechanically altered and therapeutic diet. The care plan, initiated earlier, identified a potential nutritional problem related to diet restrictions and listed interventions of a no added salt, mechanical soft texture diet with regular liquid consistency.

Record review showed that the physician’s order for the resident’s diet had been changed to no added salt, pureed texture, with nectar thickened liquids, with a start date of 02/03/26, but the care plan dated 03/11/26 was not updated to reflect this change. Multiple staff interviews, including with the MDS nurse, ADONs, DON, and administrator, confirmed that the resident’s diet had been changed following a speech evaluation and that the care plan should have been updated to show the pureed texture and nectar thickened liquids. Staff acknowledged that the kitchen and staff followed the diet orders rather than the care plan and reported no negative outcome for the resident, but consistently stated it was important for the care plan to contain the current diet information because it communicates the resident’s needs and how to care for him. The facility’s own Comprehensive Care Plans policy required comprehensive care plans with measurable objectives and timeframes to meet residents’ needs as identified in the assessment.